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AVP of Quality Management - Virtua Voorhees

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Job ID R1050479 Type Full Time Location Voorhees Township, New Jersey Standard Hours 40 Shift1st Shift

Job Summary:

The AVP Quality Management establishes and leads the implementation of the Virtua Quality Plan and Risk Management Plan at hospital facility(s) and any associated licensed services and drives the action plans to achieve G&O targets for Quality and Patient Safety. This hospital leader facilitates a strong working relationship with the corporate Quality department and collaborates with regulatory readiness, RCA’s and required submissions to the state DOH.

Position Responsibilities:

Accountable for analysis of G&O, quality and patient safety data and leads local clinical, physician, ancillary and operations leaders and staff in the development and implementation of strategies to achieve required results.

Leads local facility’s active participation in the Virtua Risk Management Program; including review and resolution of incident reports, data entry into RL Solutions, Safe Medical Device Act, reporting of Sentinel events, reportable events to the NJ DOH, etc.Analyzes facility specific results to identify opportunities for risk reduction and the development of successful action plans.

Leads the facility in continued readiness for TJC, NJ DOH, & CMS accreditation and licensing surveys.

Oversees facility Patient Relations and development of action plans for the improvement of patient satisfaction. Ensures the complaint and grievance process is being followed, events are being recorded and responded to in a timely fashion.

Mentors and coaches unit and department directors in quality and patient safety goals, in analysis of their dashboards and the development of unit based action plans that cascade upward and contribute positively into facility results.

A local senior leader and a member of Operations Management Group.Takes administrative call. Provides twenty-four hour, facility wide accountability for all quality and risk issues.

Serves as the Chair of the local QAPI Council, Code Blue Review Team, Mortality Review Team and other system and local interdisciplinary committees as appropriate to coordinate and implement quality and safety initiatives based on outcomes.

Manages the allocation of resources for the local infection control practitioner(s).  Collaborates with Chief Infectious Disease Officer and ICP to analyze local infection data and helps develop and implements successful strategies and allocate resources for infection prevention.

Manages the local resources for the collection of data for quality specific measures, TJC, NJ DOH, CMS, and Medical Staff Peer Review and ensure accurate chart documentation that serves as the foundation for APR-DRG’s and other pay for performance initiatives.

Communicates sentinel, critical or reportable events as appropriate. Participates in the root cause analysis process that is conducted by the Risk Manager. Drives action plans, collaborates with members of the Quality, Risk, Safety Work Group to disseminate information, lessons learned and findings relevant to other parts of Virtua.

Utilizing expertise in the DMAIC cycle, educates and coaches staff, managers and physicians in its use.

Position Qualifications Required / Experience Required:

Requires 5 years of healthcare leadership experience. Experience in acute care facility and a broad base of knowledge in nursing practice, evidenced based care and management.

Required Education:

Bachelor’s Degree in a health-related field.

Master’s degree preferred.

Training/Certifications/Licensure:

RN licensure.  Certification in Health Care Quality required or eligibility to sit for CPHQ Exam within 2 years.

Virtua welcomes all individuals, inclusive of race, sex, sexual orientation, gender identity, religion and faith, national origin, and disabilities, and we proudly look to each person’s unique achievements and experiences to continue to set us apart. Our whole-hearted commitment to an inclusive, diverse, and equitable workplace enables Virtua to be here for our communities, here for our patients, here for our colleagues—Here for Good.

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  • Mission:

    Virtua helps you be well, get well, and stay well.

  • Vision:

    The trusted choice for personalized health care and wellness.

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